Healthcare Provider Details

I. General information

NPI: 1699414771
Provider Name (Legal Business Name): JESSICA NICOLE WRIGHT LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 WHITE OAK ST
ASHEBORO NC
27203-5434
US

IV. Provider business mailing address

5208 WOOD VALLEY DR
RALEIGH NC
27613-6342
US

V. Phone/Fax

Practice location:
  • Phone: 336-625-5151
  • Fax:
Mailing address:
  • Phone: 919-508-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4892
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: